Introduction

This is largely an experienced-based clinical chapter. In particular, Table 15.1 outlines my professional opinion and experience with various orthoses for a range of clinical presentations.

**Table 15.1** Summary of various orthotic devices used in the author’s clinical practice
	Indication	Child’s age	Benefits	Pitfalls
AJ = ankle jerk
F/L = full length
HAV = hallux valgus
met = metatarsal
MTA = metatarsus adductus.
NWB = non-weight-bearing.
SX = symptom
TEV = talipes equinovarus.
Torsional splints
Denis Browne splint	1. Lower leg torsion/position 2. Post casting: TEV/MTA	0–5 0–3 (MTA) 0–10 (TEV)	Strong, durable	Heavy
Ganley splint	1. Lower leg torsion/ position 2. Post casting: TEV/MTA	0–3 (MTA) 0–4 (TEV)	Provides positioning of forefoot to rear foot	Time-consuming to fit; unattractive metallic bars/plates
Counter rotation splint	1. Lower leg torsion/position 2. Post casting: TEV/MTA	0–4 0–4	Hinged bar allows motion, well tolerated	No longer available; easily broken; expensive but best accepted
Unibar	1. Lower leg torsion/position 2. Post casting: TEV/MTA	0–4 0–4	360° positioning of foot to bar; lightweight	Not easily available
Fillauer bar	1. Lower leg torsion/position 2. Post casting: TEV/MTA	0–5 0–3 (MTA) 0–10 (TEV)	Clips onto existing footwear	Heavy; clamps often tear sheets
Wheaton brace	1. MTA 2. TEV 3. Calcaneovalgus 4. Intoe, out-toe	0–2	Does not attach the feet in the manner of bars Can address single foot problems	Not always a sufficiently specific fit; can be hot to wear
Other splints and devices
NSS	Equinus	4–15	Maintains ankle position at rest, yet removable Can adjust ankle position/time	Can be hot to wear. Variable comfort reported
Cast walker	# e.g. 5th met Ankle inv injury Sever’s	Need to be old enough to manage necessary gait adaptation	Maintains activity and bone stress, yet immobilizes rear foot regions	Must even up limb length with contralateral shoe
Customized foot wedging, orthoses and splints
Triplane wedges	Non-developmental flat feet, hypotonia, hypermobilty	1–5	Cheap, simple, effective	Glued into one pair of shoes
Gait plates	Intoe with tripping, falling	3–10	Cheap simple, often effective	Need a flexible sole shoe
Thermoplastics, e.g. Aquaplast	Hypermobile flat foot Mild hemiplegia Mild ankle equinus Hallux valgus	1–6	Individualized, easy application for hypermobile feet and mild neuromotor tone cases	Takes some practice to perfect fabrication; not durable
Customized foot orthoses (from foot cast/scan)	Not generally required in children under 10 years		Addresses asymmetry e.g. hemiplegia, size, deformity, trauma. Can use very durable materials	Expensive
Prefabricated foot wedging, orthoses
Valgus wedges	Variation on triplane wedges	1–5	Cheap, simple, effective	Need to be well positioned to avoid rubbing
Heel cups	Rear foot instability	1–3	Rear foot instability (often hypermobile new or late walkers) when footwear support is beneficial but insufficient	Quickly outgrown (6/12). Require well-secured shoes as movement irritates. Tendency for slippage
Heel raises	Sever’s and equinus – sport Sx – hemiplegia	8–14	Provide quick reduction of calcaneal apophysis traction and resulting symptoms of Sever’s cases	Should only be used to alleviate initial symptoms and for sport. Full-time use contributes to equinus
Prefabricated foot orthoses (a) rearfoot	Rear foot compensations (NWB rear foot to forefoot congruent)	5–15 +	Quick, cheap, effective. Can be adapted with extrinsic posting	Sand in shoes reduces durability – advise parents to empty shoes. Leave forefoot space if sock liner is removed (easily filled)
Prefabricated foot orthoses F/L (b) midfoot	Forefoot compensations (NWB rearfoot to leg basically congruent)	5–15 +	Quick, cheap, effective. Can be adapted with extrinsic posting. Do not move in shoes which is ‘anti-blistering’ for sports	Do not always transfer well between different shoe styles due to specific full-length trim. Less durable than -length style (not a big issue when considering foot growth)

Footwear selection is often fundamental and intrinsic to the use of foot orthoses and in-shoe wedging and also for the use of torsional splints (Ch. 14).

Footwear and attached splints are also an integral part of the management of metatarsus adductus (Ch. 9) and talipes equinovarus (Ch. 8).

Key Concepts

The efficacy and benefit of foot orthoses for adults is not in doubt (Landorf & Keenan 2000). Much less is known, however, about the value of foot orthoses for children, in whom there is well-founded concern about unnecessary and expensive use of foot orthoses (Pfeiffer et al 2006; Rome et al 2006; Staheli, 1987 and Staheli, 1999; Wenger et al 1989; Whitford & Esterman 2007).

Classification of children’s flat foot types assists the clinical decision-making process regarding development, monitoring and treatment need or options. Using the paediatric flat foot proforma (p-FFP; Evans 2007) may clarify this sometimes murky and poorly rationalized process for clinicians and parents (see Ch. 6). While less common, excessive supination may also require foot orthoses.

Splints, boots and in-shoe orthoses

Splints (and bars)

By definition, splints are used to hold a structural position with the rationale of moulding or training these structural tissues into the held position.

The saying ‘just as the twig is bent, so is the tree inclined’ (attributed to Alexander Pope) was long held to be true by clinicians and underpinned the prescription of physical limb and foot splinting for decades (Evans 2007; Ganley, 1984 and Ganley, 1987; Kite 1967). The ability of tissues to respond (stress, strain, form and deform) is not in question here; it is a basic physical property. However, the use of externally applied and worn splints to intrinsically alter foot and leg morphology is well disputed and hence the current decline of the use of most orthopaedic splints. An exception to this is the use of the Ilizarov bone pin external fixation devices which apply forces direct to osseous tissues and are used for fractures, bony torsions, bone length deficits (applied with adjusted tractioning) (Herzenberg et al 1994).

Alongside the questioning of splint efficacy, there has also emerged better knowledge and understanding of the normal developmental trends which exist in the paediatric population: for example, in the past orthopaedic clinics have been quite keen to treat children who presented with an intoeing gait and Denis Browne bars were frequently dispensed to correct the presumed deformity of (medial/internal) tibial torsion. We now question this approach on four main grounds:

1. Some 30% of children under 4 years of age intoe (Thackeray, Beeson, 1996a and Thackeray, Beeson, 1996b).

2. Tibial torsion is expected to be neutral at birth (Cusick 1990, Eckhoff & Johnson 1994).

3. Medial genicular (soft tissue) positioning is commonly mistaken for real tibial torsion (Cusick 1990).

4. The normal angle of gait is −8° to +16° (Losel et al 1996).

There are, however, still applications for which splinting is supported. The maintenance splint for babies with clubfoot who are treated with the Ponseti method has been shown to be a critical factor in the success rate of this ‘gold standard’ technique (Cooper & Dietz 1995; Dobbs et al 2004; Haft et al 2007; Herzenberg et al 2002; Gupta et al 2008; Morcuende et al, 2004 and Morcuende et al, 2005; Ponseti et al, 2003 and Ponseti et al, 2006; Thacker et al 2005; see Ch. 8).

Splinting is also widely used in children with muscular hypertonic conditions and cerebral palsy (Allington et al 2002, Galli et al 2001). In these cases the use of splinting is usually aimed at maintaining muscle length, preventing contracture or shortening, and in doing so reducing the intrinsically deforming forces on young bones (Fabry et al 1994, Kumar & MacEwen 1982).

Night stretch splints

The use of rest or stretch splints often worn at night-time can be useful for children with Sever’s disease (calcaneal apophysitis), idiopathic toe walking and Achilles tendon strains and shortening (Alvarez et al 2007, Evans 2001, Hemo et al 2006). These splints address sagittal plane positions and range of motion and can be rigid, adjustable or a sock and strap system (see Fig. 11.4).

These splints capitalize on the connective tissue property of ‘creep’ – its ability to plastically deform under maintained tensile load. The use of a dorsiflexion toe wedge can add further fascial stretch. Some splints have the foot/leg angle adjustable from 20° plantarflexion to 20° dorsiflexion in 10° increments, which allows for increased stretch loading as the range increases.

While the Denis Browne bar has been and remains the mainstay of torsional splints, there have been a number of other popular devices which will be briefly described (Fig. 15.1).

Figure 15.1

(A) Denis Browne bar (bent for clubfoot maintenance). (B) Fitting a torsion splint with Markell splint boots.

Ganley splint

Invented by the late Dr James Ganley DPM (who I was privileged to be hosted and mentored by when studying in Pennsylvania). This is a combination torsion splint with the ability to simultaneously adjust forefoot to rear foot and also foot to leg in all three cardinal body planes. It was designed primarily for the maintenance of metatarsus adductus following corrective serial casting. It can also be used for calcaneovalgus foot deformities and concurrent lower limb rotational problems (Ganley, 1984 and Ganley, 1991).

Counter rotation system (CRS)

This innovative and almost attractive splint was produced by the Langer Corporation in New York. As the name suggests, this splint addresses lower limb rotations, e.g. intoe. Made of white plastic, the multiple hinged joints made this the most user-friendly splint as, unlike all other anti-torsion splints, the rigid bar was replaced with a mobile framework, allowing more movement and better compliance (Fig. 15.2).